Abdominal Exam Flashcards
(19 cards)
General inspection
Abdominal distention – ascites / bowel distension / large masses
Masses – may suggest malignancy / organomegaly
Excoriations – pruritus – cholestasis - Cholestasis is reduction or stoppage of bile flow. Disorders of the liver, bile duct, or pancreas can cause cholestasis. The skin and whites of the eyes look yellow, the skin itches, urine is dark, and stools may become light-colored and smell foul.
Anaemia – obvious pallor suggests significant anaemia – e.g. GI bleeding
Inspection - Hands
Hands
Clubbing – inflammatory bowel disease / cirrhosis / coeliac disease
Koilonychia – spooning of the nails – chronic iron deficiency
Leukonychia – whitened nail bed – hypoalbuminemia (liver failure / enteropathy)
Palmar erythema – reddening of palms – liver disease / pregnancy
Dupuytren’s contracture is a condition in which one or more fingers become permanently bent in a flexed position. It usually begins as small hard nodules just under the skin of the palm, then worsens over time until the fingers can no longer be straightened (alcohol use or family history)
what is Asterixis? (hand flapping)
caused by abnormal function of the diencephalic motor centers in the brain, which regulate the muscles involved in maintaining position.
Asterixis is seen most often in drowsy or stuporous patients with metabolic encephalopathies, especially in decompensated cirrhosis or acute liver failure.
Asterixis is also seen in respiratory failure due to carbon dioxide toxicity (hypercapnia).
Some drugs are known to cause asterixis, particularly phenytoin (when it is known as phenytoin flap). Other drugs implicated include benzodiazepines, barbiturates, valproate, gabapentin, lithium, ceftazidime, and metoclopramide.
It can be a sign of hepatic encephalopathy, damage to brain cells presumably due to the inability of the liver to metabolize ammonia to urea. The cause is thought to be predominantly related to abnormal ammonia metabolism.[3]
Eyes
Xanthelasma – raised yellow deposits surrounding eyes – hyperlipidaemia
Ask patient to lower one of their eyelids with their finger. Inspect for the signs below.
Conjunctival pallor – suggests significant anaemia
Jaundice – noted in the sclera – haemolysis / hepatitis / cirrhosis / biliary obstructio
Mouth
Angular stomatitis – inflamed red areas at the corners of the mouth – iron/B12 deficiency
Oral candidiasis – white slough on oral mucous membranes – iron deficiency / immunodeficiency
Mouth ulcers – Crohn’s disease / coeliac disease
Tongue (glossitis) – smooth swelling of the tongue with associated erythema – iron/B12/folate deficiency
Neck
Cervical lymph nodes – lymphadenopathy may indicate infection / metastatic malignancy
Virchow’s node – left supraclavicular fossa – suggestive of gastric malignancy
Chest
Spider naevi – central red spot with reddish extensions (>5 significant) – chronic liver disease
Gynaecomastia – overdevelopment of male mammary glands (pseudofeminisation) – liver cirrhosis / digoxin/ spironolactone
Hair loss – pseudofeminisation/ malnourishment / iron deficiency anaemia
Detailed abdominal inspection
Pulsation – a central pulsatile and expansile mass may indicate an abdominal aortic aneurysm (AAA)
Cullen’s sign – bruising surrounding umbilicus – retroperitoneal bleed (pancreatitis/ruptured AAA)
Grey-Turner’s sign – bruising in the flanks – retroperitoneal bleed (pancreatitis/ruptured AAA)
Abdominal distension – fluid (ascites) / fat (obesity) / faeces (constipation) / flatus / fetus (pregnancy)
Liver
- Begin palpation in the right iliac fossa using the flat edge of your hand (radial side of your right index finger)
- Press your hand into the abdomen as you ask the patient to take a deep breath
- Feel for a step, as the liver edge passes below your hand
- If you don’t feel anything, repeat the process with your hand 1-2 cm higher
\Degree of extension below the costal margin
Consistency of the liver edge (smooth/irregular)
Tenderness – suggestive of hepatitis
Pulsatility – a pulsatile enlarged liver can be caused by tricuspid regurgitation
Gallbladder
The gallbladder is not usually palpable.
An enlarged gallbladder suggests obstruction to biliary flow/infection (cholecystitis).
Perform palpation at the right costal margin, mid-clavicular line (9th rib tip).
If enlarged, a rounded mass moving with respiration may be palpated (note any tenderness)
Murphy’s sign:
Place your hand in the area noted above (right costal margin, mid-clavicular line)
Ask the patient to take a deep breath
As the gallbladder is pushed down into your hand the patient may suddenly develop pain and stop inspiring.
If this occurs and there is no discomfort in the same location on the left side of the abdomen then this is known as a positive Murphy’s sign, which is suggestive of cholecystitis (painful gallbladder via stones)
Spleen
The spleen only becomes palpable when it’s at least three times its normal size!
- Start in right iliac fossa – massive splenomegaly can extend this far!
- Align your fingers in the same direction as the left costal margin
- Press your right hand into the abdomen as you ask the patient to take a deep breath
- Feel for a step, as the splenic edge passes under your hand (a notch may be noted)
Kidneys
. Place your left hand behind the patient’s back, at the right flank
- Place your right hand just below the right costal margin in the right flank
- Press your right hand’s fingers deep into the abdomen
- At the same time press upwards with your left hand
- Ask the patient to take a deep breath
- You may feel the lower pole of the kidney moving inferiorly during inspiration
- Repeat this process on the opposite side to assess the left kidney
Aorta
- Palpate using fingers from both hands
- Palpate just above the umbilicus at the border of the aortic pulsation
- Note the movement of your fingers:
Upward movement = pulsatile
Outward movement = expansile (suggestive of AAA)
Percussion
Abdominal organs
Liver – percuss up from RIF then down from right side of chest to determine the size of the liver
Spleen – percuss up from RIF moving towards the left hypochondrium to assess for splenomegaly
Bladder – percuss suprapubic region – differentiating suprapubic masses (bladder (dull) / bowel (resonant))
Auscultation
Bowel sounds
Normal – gurgling
Abnormal – e.g. “tinkling” (bowel obstruction)
Absent – ileus / peritonitis
Bruits
Aortic bruits – auscultate just above the umbilicus – AAA
Renal bruits – auscultate just above the umbilicus, slightly lateral to the midline
AAA causes?
Hardening of the arteries (atherosclerosis).
Atherosclerosis occurs when fat and other substances build up on the lining of a blood vessel.
High blood pressure. High blood pressure can damage and weaken the aorta’s walls.
Blood vessel diseases. These are diseases that cause blood vessels to become inflamed.
Infection in the aorta. Rarely, a bacterial or fungal infection might cause an abdominal aortic aneurysms.
Trauma. For example, being in a car accident can cause an abdominal aortic aneurysms.
AAA risk factors?
Tobacco use. Smoking is the strongest risk factor. It can weaken the aortic walls, increasing the risk not only of developing an aortic aneurysm, but of rupture. The longer and more you smoke or chew tobacco, the greater the chances of developing an aortic aneurysm.
Age. These aneurysms occur most often in people age 65 and older.
Being male. Men develop abdominal aortic aneurysms much more often than women do.
Being white. People who are white are at higher risk of abdominal aortic aneurysms.
Family history. Having a family history of abdominal aortic aneurysms increases your risk of having the condition.
Other aneurysms. Having an aneurysm in another large blood vessel, such as the artery behind the knee or the aorta in the chest, might increase your risk of an abdominal aortic aneurysm.
AAA signs and symptoms?
Sudden, intense and persistent abdominal or back pain, which can be described as a tearing sensation
Low blood pressure
Fast pulse
